Provider Demographics
NPI:1376237149
Name:REVOREDO, ANDREA E
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:REVOREDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 US HIGHWAY 9 APT 2-M
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:971 US HIGHWAY 9 APT 2-M
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-2002
Practice Address - Country:US
Practice Address - Phone:732-670-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP49612000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse